Endovascular Thrombectomy Versus Medical Therapy Alone in Patients With Large Core Based on Computed Tomography Perfusion

Abstract

Background Patients presenting with large vessel occlusion and a large ischemic core (>50 mL) have been consistently undersampled in the major endovascular thrombectomy (ET) trials. As such, equipoise exists as to whether ET is associated with improved outcomes over medical therapy alone in this population. Methods Prospectively collected databases from 4 US centers were reviewed to identify patients with baseline ischemic cores >50 mL based on computed tomography perfusion imaging using RAPID software (iSchemaView), who were treated with ET or medical therapy alone between January 2014 and October 2019. Baseline characteristics, procedural information, and clinical follow‐up data were collected. A matched‐control comparison of these patients was performed. Results A total of 167 patients were included, of whom 92 received medical therapy alone and 75 underwent ET. Seventy‐five pairs were obtained after matching for baseline ischemic core volume, National Institutes of Health Stroke Scale score, and age. Rate of 90‐day good outcome was significantly higher in the ET arm (28.4% versus 4.9%, P=0.002). In univariate analysis of ET patients, the rate of good outcome was significantly higher among patients treated within <6 hours compared with ≥6 hours (44.2% versus 17.4%, P=0.02). Predictors of good outcome included age (P=0.008), ischemic core volume (P=0.01), and time from last known well to groin puncture (P=0.004). Conclusions ET was associated with improved outcomes in patients with large ischemic core based on computed tomography perfusion. This association was more pronounced in patients who present early (<6 hours from last seen well) with an adequate target mismatch. These results may guide the practice until data from ongoing randomized trials become available.

Keywords

• cerebral infarction
• perfusion imaging
• stroke
• thrombectomy